|
CARVEDILOL 6.25 MG TABLET [15747]
|
Facility
OP
|
$0.07
|
|
|
Service Code
|
NDC 68462-163-01
|
| Hospital Charge Code |
1711680
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.06
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.06
|
| Rate for Payer: Dignity Health Senior |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Senior |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Vantage Medical Group Senior |
$0.06
|
|
|
CARVEDILOL ORAL SUSPENSION COMPOUND 1.25 MG/ML [4080253]
|
Facility
IP
|
$0.10
|
|
|
Service Code
|
NDC 9994-0802-53
|
| Hospital Charge Code |
1715276
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
CARVEDILOL ORAL SUSPENSION COMPOUND 1.25 MG/ML [4080253]
|
Facility
OP
|
$0.10
|
|
|
Service Code
|
NDC 9994-0802-53
|
| Hospital Charge Code |
1715276
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Senior |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
CARVEDILOL PHOSPHATE ER 10 MG CAPSULE,EXT.RELEASE24HR MULTIPHASE [77664]
|
Facility
OP
|
$9.91
|
|
|
Service Code
|
NDC 57664-663-83
|
| Hospital Charge Code |
1711920
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.79 |
| Max. Negotiated Rate |
$8.42 |
| Rate for Payer: Adventist Health Commercial |
$1.98
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.81
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$8.42
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.45
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.43
|
| Rate for Payer: Blue Shield of California Commercial |
$6.15
|
| Rate for Payer: Blue Shield of California EPN |
$5.82
|
| Rate for Payer: Cash Price |
$4.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.42
|
| Rate for Payer: Dignity Health Senior |
$8.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.13
|
| Rate for Payer: Heritage Provider Network Senior |
$6.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.48
|
| Rate for Payer: Multiplan Commercial |
$7.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.42
|
| Rate for Payer: Vantage Medical Group Senior |
$8.42
|
|
|
CARVEDILOL PHOSPHATE ER 10 MG CAPSULE,EXT.RELEASE24HR MULTIPHASE [77664]
|
Facility
IP
|
$9.91
|
|
|
Service Code
|
NDC 57664-663-83
|
| Hospital Charge Code |
1711920
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.79 |
| Max. Negotiated Rate |
$7.43 |
| Rate for Payer: Adventist Health Commercial |
$1.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.81
|
| Rate for Payer: Cash Price |
$4.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.71
|
| Rate for Payer: Heritage Provider Network Senior |
$6.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.48
|
| Rate for Payer: Multiplan Commercial |
$7.43
|
|
|
CARVEDILOL PHOSPHATE ER 10 MG CAPSULE,EXT.RELEASE24HR MULTIPHASE [77664]
|
Facility
IP
|
$9.91
|
|
|
Service Code
|
NDC 69784-713-13
|
| Hospital Charge Code |
1711920
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.79 |
| Max. Negotiated Rate |
$7.43 |
| Rate for Payer: Adventist Health Commercial |
$1.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.81
|
| Rate for Payer: Cash Price |
$4.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.71
|
| Rate for Payer: Heritage Provider Network Senior |
$6.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.48
|
| Rate for Payer: Multiplan Commercial |
$7.43
|
|
|
CARVEDILOL PHOSPHATE ER 10 MG CAPSULE,EXT.RELEASE24HR MULTIPHASE [77664]
|
Facility
OP
|
$9.91
|
|
|
Service Code
|
NDC 69784-713-13
|
| Hospital Charge Code |
1711920
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.79 |
| Max. Negotiated Rate |
$8.42 |
| Rate for Payer: Adventist Health Commercial |
$1.98
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.81
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$8.42
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.45
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.43
|
| Rate for Payer: Blue Shield of California Commercial |
$6.15
|
| Rate for Payer: Blue Shield of California EPN |
$5.82
|
| Rate for Payer: Cash Price |
$4.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.42
|
| Rate for Payer: Dignity Health Senior |
$8.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.13
|
| Rate for Payer: Heritage Provider Network Senior |
$6.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.48
|
| Rate for Payer: Multiplan Commercial |
$7.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.42
|
| Rate for Payer: Vantage Medical Group Senior |
$8.42
|
|
|
CARVEDILOL PHOSPHATE ER 20 MG CAPSULE,EXT.RELEASE24HR MULTIPHASE [77665]
|
Facility
IP
|
$9.51
|
|
|
Service Code
|
NDC 60505-4714-3
|
| Hospital Charge Code |
1711921
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.72 |
| Max. Negotiated Rate |
$7.13 |
| Rate for Payer: Adventist Health Commercial |
$1.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.53
|
| Rate for Payer: Cash Price |
$4.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.44
|
| Rate for Payer: Heritage Provider Network Senior |
$6.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.38
|
| Rate for Payer: Multiplan Commercial |
$7.13
|
|
|
CARVEDILOL PHOSPHATE ER 20 MG CAPSULE,EXT.RELEASE24HR MULTIPHASE [77665]
|
Facility
IP
|
$9.51
|
|
|
Service Code
|
NDC 60505-3679-3
|
| Hospital Charge Code |
1711921
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.72 |
| Max. Negotiated Rate |
$7.13 |
| Rate for Payer: Adventist Health Commercial |
$1.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.53
|
| Rate for Payer: Cash Price |
$4.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.44
|
| Rate for Payer: Heritage Provider Network Senior |
$6.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.38
|
| Rate for Payer: Multiplan Commercial |
$7.13
|
|
|
CARVEDILOL PHOSPHATE ER 20 MG CAPSULE,EXT.RELEASE24HR MULTIPHASE [77665]
|
Facility
OP
|
$9.51
|
|
|
Service Code
|
NDC 60505-4714-3
|
| Hospital Charge Code |
1711921
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.72 |
| Max. Negotiated Rate |
$8.08 |
| Rate for Payer: Adventist Health Commercial |
$1.90
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.53
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$8.08
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.23
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.13
|
| Rate for Payer: Blue Shield of California Commercial |
$5.91
|
| Rate for Payer: Blue Shield of California EPN |
$5.58
|
| Rate for Payer: Cash Price |
$4.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.08
|
| Rate for Payer: Dignity Health Senior |
$8.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.89
|
| Rate for Payer: Heritage Provider Network Senior |
$5.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.38
|
| Rate for Payer: Multiplan Commercial |
$7.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.08
|
| Rate for Payer: Vantage Medical Group Senior |
$8.08
|
|
|
CARVEDILOL PHOSPHATE ER 20 MG CAPSULE,EXT.RELEASE24HR MULTIPHASE [77665]
|
Facility
OP
|
$9.51
|
|
|
Service Code
|
NDC 60505-3679-3
|
| Hospital Charge Code |
1711921
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.72 |
| Max. Negotiated Rate |
$8.08 |
| Rate for Payer: Adventist Health Commercial |
$1.90
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.53
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$8.08
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.23
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.13
|
| Rate for Payer: Blue Shield of California Commercial |
$5.91
|
| Rate for Payer: Blue Shield of California EPN |
$5.58
|
| Rate for Payer: Cash Price |
$4.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.08
|
| Rate for Payer: Dignity Health Senior |
$8.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.89
|
| Rate for Payer: Heritage Provider Network Senior |
$5.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.38
|
| Rate for Payer: Multiplan Commercial |
$7.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.08
|
| Rate for Payer: Vantage Medical Group Senior |
$8.08
|
|
|
CARVEDILOL PHOSPHATE ER 20 MG CAPSULE,EXT.RELEASE24HR MULTIPHASE [77665]
|
Facility
IP
|
$9.91
|
|
|
Service Code
|
NDC 69784-714-13
|
| Hospital Charge Code |
1711921
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.79 |
| Max. Negotiated Rate |
$7.43 |
| Rate for Payer: Adventist Health Commercial |
$1.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.81
|
| Rate for Payer: Cash Price |
$4.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.71
|
| Rate for Payer: Heritage Provider Network Senior |
$6.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.48
|
| Rate for Payer: Multiplan Commercial |
$7.43
|
|
|
CARVEDILOL PHOSPHATE ER 20 MG CAPSULE,EXT.RELEASE24HR MULTIPHASE [77665]
|
Facility
OP
|
$9.91
|
|
|
Service Code
|
NDC 57664-664-83
|
| Hospital Charge Code |
1711921
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.79 |
| Max. Negotiated Rate |
$8.42 |
| Rate for Payer: Adventist Health Commercial |
$1.98
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.81
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$8.42
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.45
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.43
|
| Rate for Payer: Blue Shield of California Commercial |
$6.15
|
| Rate for Payer: Blue Shield of California EPN |
$5.82
|
| Rate for Payer: Cash Price |
$4.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.42
|
| Rate for Payer: Dignity Health Senior |
$8.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.13
|
| Rate for Payer: Heritage Provider Network Senior |
$6.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.48
|
| Rate for Payer: Multiplan Commercial |
$7.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.42
|
| Rate for Payer: Vantage Medical Group Senior |
$8.42
|
|
|
CARVEDILOL PHOSPHATE ER 20 MG CAPSULE,EXT.RELEASE24HR MULTIPHASE [77665]
|
Facility
OP
|
$9.91
|
|
|
Service Code
|
NDC 69784-714-13
|
| Hospital Charge Code |
1711921
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.79 |
| Max. Negotiated Rate |
$8.42 |
| Rate for Payer: Adventist Health Commercial |
$1.98
|
| Rate for Payer: Aetna of CA Gatekeeper |
$5.30
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.81
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$8.42
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.45
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$7.43
|
| Rate for Payer: Blue Shield of California Commercial |
$6.15
|
| Rate for Payer: Blue Shield of California EPN |
$5.82
|
| Rate for Payer: Cash Price |
$4.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.42
|
| Rate for Payer: Dignity Health Senior |
$8.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.13
|
| Rate for Payer: Heritage Provider Network Senior |
$6.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.48
|
| Rate for Payer: Multiplan Commercial |
$7.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.42
|
| Rate for Payer: Vantage Medical Group Senior |
$8.42
|
|
|
CARVEDILOL PHOSPHATE ER 20 MG CAPSULE,EXT.RELEASE24HR MULTIPHASE [77665]
|
Facility
IP
|
$9.91
|
|
|
Service Code
|
NDC 57664-664-83
|
| Hospital Charge Code |
1711921
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.79 |
| Max. Negotiated Rate |
$7.43 |
| Rate for Payer: Adventist Health Commercial |
$1.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.81
|
| Rate for Payer: Cash Price |
$4.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.71
|
| Rate for Payer: Heritage Provider Network Senior |
$6.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.48
|
| Rate for Payer: Multiplan Commercial |
$7.43
|
|
|
CASPOFUNGIN 50 MG INTRAVENOUS SOLUTION [29567]
|
Facility
OP
|
$85.44
|
|
|
Service Code
|
CPT J0637
|
| Hospital Charge Code |
1759988
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.99 |
| Max. Negotiated Rate |
$72.62 |
| Rate for Payer: Adventist Health Commercial |
$17.09
|
| Rate for Payer: Adventist Health Commercial |
$16.56
|
| Rate for Payer: Aetna of CA Gatekeeper |
$13.33
|
| Rate for Payer: Aetna of CA Gatekeeper |
$13.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$56.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$58.70
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$70.38
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$72.62
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$45.54
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$46.99
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$62.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$64.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$64.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$64.13
|
| Rate for Payer: Blue Shield of California Commercial |
$9.99
|
| Rate for Payer: Blue Shield of California Commercial |
$9.99
|
| Rate for Payer: Blue Shield of California EPN |
$9.99
|
| Rate for Payer: Blue Shield of California EPN |
$9.99
|
| Rate for Payer: Cash Price |
$37.26
|
| Rate for Payer: Cash Price |
$38.45
|
| Rate for Payer: Cash Price |
$37.26
|
| Rate for Payer: Cash Price |
$38.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$38.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$39.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$70.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$72.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$70.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$72.62
|
| Rate for Payer: Dignity Health Senior |
$70.38
|
| Rate for Payer: Dignity Health Senior |
$72.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$52.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$54.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$39.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$38.34
|
| Rate for Payer: Heritage Provider Network Senior |
$38.34
|
| Rate for Payer: Heritage Provider Network Senior |
$39.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$39.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$41.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.70
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.36
|
| Rate for Payer: Multiplan Commercial |
$62.10
|
| Rate for Payer: Multiplan Commercial |
$64.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$30.19
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$31.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$28.55
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$27.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$70.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$72.62
|
| Rate for Payer: Vantage Medical Group Senior |
$72.62
|
| Rate for Payer: Vantage Medical Group Senior |
$70.38
|
|
|
CASPOFUNGIN 50 MG INTRAVENOUS SOLUTION [29567]
|
Facility
IP
|
$82.80
|
|
|
Service Code
|
CPT J0637
|
| Hospital Charge Code |
1759988
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.99 |
| Max. Negotiated Rate |
$62.10 |
| Rate for Payer: Adventist Health Commercial |
$16.56
|
| Rate for Payer: Adventist Health Commercial |
$17.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$58.70
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$56.88
|
| Rate for Payer: Cash Price |
$38.45
|
| Rate for Payer: Cash Price |
$37.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$38.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$39.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$46.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$44.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$56.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$57.84
|
| Rate for Payer: Heritage Provider Network Senior |
$57.84
|
| Rate for Payer: Heritage Provider Network Senior |
$56.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.70
|
| Rate for Payer: Multiplan Commercial |
$62.10
|
| Rate for Payer: Multiplan Commercial |
$64.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$30.19
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$31.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$27.66
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$28.55
|
|
|
CASPOFUNGIN 70 MG INTRAVENOUS SOLUTION [29568]
|
Facility
IP
|
$118.80
|
|
|
Service Code
|
CPT J0637
|
| Hospital Charge Code |
1759997
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.50 |
| Max. Negotiated Rate |
$89.10 |
| Rate for Payer: Adventist Health Commercial |
$23.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$81.62
|
| Rate for Payer: Cash Price |
$53.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$54.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$80.43
|
| Rate for Payer: Heritage Provider Network Senior |
$80.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.70
|
| Rate for Payer: Multiplan Commercial |
$89.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$43.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$39.69
|
|
|
CASPOFUNGIN 70 MG INTRAVENOUS SOLUTION [29568]
|
Facility
OP
|
$118.80
|
|
|
Service Code
|
CPT J0637
|
| Hospital Charge Code |
1759997
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.99 |
| Max. Negotiated Rate |
$100.98 |
| Rate for Payer: Adventist Health Commercial |
$23.76
|
| Rate for Payer: Aetna of CA Gatekeeper |
$13.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$81.62
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$100.98
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$65.34
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$89.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$64.13
|
| Rate for Payer: Blue Shield of California Commercial |
$9.99
|
| Rate for Payer: Blue Shield of California EPN |
$9.99
|
| Rate for Payer: Cash Price |
$53.46
|
| Rate for Payer: Cash Price |
$53.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$54.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$100.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$100.98
|
| Rate for Payer: Dignity Health Senior |
$100.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$76.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$55.00
|
| Rate for Payer: Heritage Provider Network Senior |
$55.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$57.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.70
|
| Rate for Payer: Multiplan Commercial |
$89.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$43.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$39.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$100.98
|
| Rate for Payer: Vantage Medical Group Senior |
$100.98
|
|
|
Cautery of cervix; laser ablation
|
Facility
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 57513
|
| Min. Negotiated Rate |
$343.06 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$2,869.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5,859.27
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4,296.80
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3,906.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4,547.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5,859.27
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,296.80
|
| Rate for Payer: Dignity Health Senior |
$3,906.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$3,906.18
|
| Rate for Payer: Humana Medicare |
$3,906.18
|
| Rate for Payer: IEHP Medi-Cal |
$343.06
|
| Rate for Payer: IEHP Medicare Advantage |
$3,906.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$7,421.74
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$4,609.29
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$4,921.79
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$4,921.79
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,296.80
|
| Rate for Payer: TriValley Medical Group Senior |
$3,906.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$5,859.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,296.80
|
| Rate for Payer: Vantage Medical Group Senior |
$3,906.18
|
|
|
CEFACLOR 250 MG/5 ML ORAL SUSPENSION [9434]
|
Facility
OP
|
$1.40
|
|
|
Service Code
|
NDC 16571-071-12
|
| Hospital Charge Code |
NDG9434
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.19 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.96
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.19
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.77
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.87
|
| Rate for Payer: Blue Shield of California EPN |
$0.82
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.91
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.19
|
| Rate for Payer: Dignity Health Senior |
$1.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.87
|
| Rate for Payer: Heritage Provider Network Senior |
$0.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.19
|
| Rate for Payer: Vantage Medical Group Senior |
$1.19
|
|
|
CEFACLOR 250 MG/5 ML ORAL SUSPENSION [9434]
|
Facility
IP
|
$1.40
|
|
|
Service Code
|
NDC 16571-071-12
|
| Hospital Charge Code |
NDG9434
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.96
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.95
|
| Rate for Payer: Heritage Provider Network Senior |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$1.05
|
|
|
CEFACLOR 500 MG CAPSULE [9431]
|
Facility
OP
|
$2.86
|
|
|
Service Code
|
NDC 61442-172-30
|
| Hospital Charge Code |
1712040
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$2.43 |
| Rate for Payer: Adventist Health Commercial |
$0.57
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.96
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.43
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.57
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.14
|
| Rate for Payer: Blue Shield of California Commercial |
$1.78
|
| Rate for Payer: Blue Shield of California EPN |
$1.68
|
| Rate for Payer: Cash Price |
$1.29
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.86
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.43
|
| Rate for Payer: Dignity Health Senior |
$2.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.83
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.77
|
| Rate for Payer: Heritage Provider Network Senior |
$1.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$2.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.43
|
| Rate for Payer: Vantage Medical Group Senior |
$2.43
|
|
|
CEFACLOR 500 MG CAPSULE [9431]
|
Facility
IP
|
$2.86
|
|
|
Service Code
|
NDC 61442-172-30
|
| Hospital Charge Code |
1712040
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$2.14 |
| Rate for Payer: Adventist Health Commercial |
$0.57
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.96
|
| Rate for Payer: Cash Price |
$1.29
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.94
|
| Rate for Payer: Heritage Provider Network Senior |
$1.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.72
|
| Rate for Payer: Multiplan Commercial |
$2.14
|
|
|
CEFADROXIL 500 MG CAPSULE [9436]
|
Facility
IP
|
$0.71
|
|
|
Service Code
|
NDC 0093-3196-53
|
| Hospital Charge Code |
ERX9436
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.49
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.48
|
| Rate for Payer: Heritage Provider Network Senior |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.53
|
|
